What is the treatment for refractory hypotension?

From the Guidelines

Refractory hypotension should be treated with norepinephrine as the first-line vasopressor, with a target mean arterial pressure (MAP) of at least 65 mmHg, as recommended by the most recent guidelines 1. The treatment approach should start with identifying and addressing the underlying cause of hypotension.

Key Interventions

• Intravenous fluid resuscitation with crystalloids (normal saline or lactated Ringer's) at 20-30 mL/kg should be initiated as the first-line intervention.
• If hypotension persists, norepinephrine (starting at 0.05-0.1 mcg/kg/min, titrated to effect) should be initiated as the preferred first agent due to its balanced alpha and beta effects.
• For patients not responding to norepinephrine, adding vasopressin (0.01-0.04 units/min) can provide synergistic effects without increasing catecholamine exposure, as suggested by previous studies 1.

Additional Considerations

• In cases of cardiogenic shock, dobutamine (2-20 mcg/kg/min) may be added for inotropic support.
• Corticosteroids (hydrocortisone 200-300 mg/day in divided doses) should be considered for patients with suspected adrenal insufficiency or those requiring high-dose vasopressors.
• Mechanical support with an intra-aortic balloon pump or ECMO may be necessary in severe cases.

Monitoring and Adjustments

• Continuous hemodynamic monitoring is essential, targeting a mean arterial pressure of at least 65 mmHg while addressing the underlying cause such as sepsis, hemorrhage, or cardiac dysfunction.
• Bedside echocardiography can be useful to evaluate volume status and cardiac function in patients with cirrhosis and hypotension or shock, as recommended by recent guidelines 1. Refractory hypotension often indicates a complex pathophysiology involving vasodilation, myocardial depression, and endocrine dysfunction, requiring a multifaceted treatment approach.

From the FDA Drug Label

For blood pressure control in certain acute hypotensive states (e.g., pheochromocytomectomy, sympathectomy, poliomyelitis, spinal anesthesia, myocardial infarction, septicemia, blood transfusion, and drug reactions). As an adjunct in the treatment of cardiac arrest and profound hypotension. The answer to hypotension treatment that's refractory is Norepinephrine (IV), as it is used for blood pressure control in certain acute hypotensive states and as an adjunct in the treatment of profound hypotension 2.

From the Research

Treatment Options for Refractory Hypotension

• Methylene blue has been shown to be effective in treating refractory hypotension, particularly in cases of anaphylaxis 3.
• The suspected mechanism of action of methylene blue is inhibition of the enzyme nitric oxide synthase, which ultimately prevents the smooth muscle dilation that accompanies anaphylaxis 3.
• A specific diagnosis of the underlying cause for the refractory hypotension can be made by thorough clinical evaluation, and specific treatment aimed at correcting the underlying cause of the vascular collapse will lower the mortality rate in this serious type of circulatory failure 4.

Fluid Resuscitation and Vasopressors

• Fluid therapy is widely used in critically ill patients to restore effective intravascular volume and improve organ perfusion, but recent studies have questioned the administration of colloid-based solutions 5.
• The use of colloids as initial fluid therapy for early resuscitation is still uncertain, and some studies suggest that mortality was not increased and probably decreased with the use of colloids in different forms of shock requiring early fluid resuscitation 5.
• There is limited high-level evidence to support the use of intravenous fluid resuscitation as first-line treatment for sepsis-associated hypotension and/or hypoperfusion, and some recommend earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock 6.

Therapeutic Considerations

• Therapeutic intervention for refractory hypotension involves fluid therapy to normalize volemia and use of sympathomimetics to enhance cardiac function and regulate peripheral vascular resistance 7.
• Proper interpretation of cardiovascular parameters, fluid recommendations and therapy rates, use of sympathomimetics and vasopressors, and newer approaches derived from the human literature are important considerations in the treatment of refractory hypotension 7.